assertiveness

Talking pain – seeking validation: Social interaction in pain


ResearchBlogging.org

While we might laugh about the so-called typical ‘I will fix it’ response of some men when their partners talk about problems (when what the woman really wants is a hug), it seems that much of our research into pain behaviour, particularly verbal expressions of pain, has missed something. I’m not a major reader of relationship literature, but I do read a lot about pain behaviour, and something I’ve noticed is the almost exclusive orientation toward the operant conditioning model when it comes to expressing pain in a social setting.

In operant model of pain behaviour, these behaviours are enacted to communicate to others. Responses to those behaviours may reinforce or punish those behaviours – and there is a good deal of evidence to support this model. It seems to be supported by evolutionary theory in that pain behaviours elicit resources from others, and serve to obtain help. One focus of therapy traditionally is to reduce the number of pain behaviours, in order to reduce the identification of the individual with helplessness or the sick role.

Cano and Williams, in this paper, suggest an alternative view of particularly verbal utterances about pain in relationships – they suggest considering an interpersonal process model of intimacy.

In this model, the things we say that disclose emotional content serve to foster and strengthen intimacy if they are met with empathy and validation. Cano and Williams state: ‘verbal communications about one’s thoughts and feelings about pain, may entail attempts to disclose emotion, recruit emotional support, and build intimacy.’
They go on to say ‘An empathic and concerned response from the partner may also contribute to intimacy. Emotional validation, including empathic responses, enhances the emotion regulation process for both partners because such responses allow each person to process stressful or aversive stimuli.’

In other words, if the partner doesn’t respond empathically, this is usually interpreted to mean rejection and disregard for the partner and usually negatively affects emotion regulation, but when the partner does respond with empathy, the relationship is stronger and more intimate.

What might this mean in therapy?
Well, up until now, operant theory has supported the idea of reducing or minimising pain behaviour, including talking about pain or eliciting emotional or practical support from a partner. This process model suggests that some types of communication may serve to improve the relationship. Validation of emotional content by the partner has in one study correlated negatively with punishing spouse responses, while invalidation correlated positively with punishing spouse responses – and the emotional content (rather than the words) made the major difference between the two types of response (Cano, Barterian & Heller, 2008).

This suggests that a simple ‘let’s eliminate the negative’ may not benefit the relationship. Strong relationships enhance coping, and relationships are strengthened when what one spouse is seeking is matched by the other spouse.

Empathy, caring, concern, and closeness may be desired when a person with pain discloses emotion, not ‘‘expertise” or problem-solving, which could signal invalidation of emotion.

This may mean clinicians helping partners (and families) learn to communicate more effectively – and something that has become very apparent to me is how poorly we as humans can communicate about pain, especially when it comes to setting boundaries, asking for help, or seeking emotional support. It takes a good deal of skill to express what it is that we really want, and to clarify or restate what we want if initially we fail to get it.

Assertiveness has a bad rap very often – it can mean all sorts of strident and aggressive ways to ‘get the point across’, when in fact it is simply about being respectful of each other and oneself.  A good number of factors can get in the way of effective communication such as long-standing scripts ‘I should be able to cope alone’, ‘I must not disagree’, ‘I don’t have the right to ask’, as well as limited skills in regulating emotions when the message isn’t received in the way it was hoped.

At the very least, something we can do as clinicians is listen to the people we are working with, and while we don’t want to reinforce helplessness (which, by the way, we will do if we offer ‘solutions’ rather than simply acknowledging the situation), we can help people feel more comfortable with difficult emotions if we ourselves can be mindful and allow ourselves to ‘sit with’ those very emotions.  By modelling effective communication ourselves, we can help validate and strengthen our relationship with the person, while not necessarily attempting to ‘fix’ or ‘reduce’ the distress.  Then we can turn the conversation to things that are good, achieved and helping the person move on.

Some brief pointers as to how:

  • ask about what the person has been up to rather than how their pain is
  • if they say they’ve had a hard time, acknowledge this ‘It’s been a real challenge to get here’.  Then pause – and add ‘it’s really great to see you here, how did you manage it’ as a way to move on towards positive coping
  • when they foresee snags or problems, acknowledge that it’s not easy to do what we’re asking.  Then ask what they think is the ‘next best step’ towards doing what you’re currently working on.
  • respond to the emotional content by empathic reflection, rather than getting caught up in how to solve the practical problem – that’s probably not what the person is asking for, and even if it is, empathy can go a long way towards helping the person accept that you are there for them rather than to ‘fix’ them

The paper by Cano and Williams goes on to discuss appropriate research strategies that might help us understand more about interactions in couples.  It’s difficult for me to read this without adding ‘if you can get the couple to come in!’ because so often people seem to think that they ‘should’ cope with ongoing pain alone.  It would be great to see far more emphasis on people and their relationships and social context in the next ‘new wave’ of chronic pain management.

Cano, A., & Williams, A. (2010). Social interaction in pain: Reinforcing pain behaviors or building intimacy? Pain, 149 (1), 9-11 DOI: 10.1016/j.pain.2009.10.010

Cano A, Barterian JA, Heller JB. Empathic and nonempathic interaction in
chronic pain couples. Clin J Pain 2008:678–84

Clear communication – an activity to encourage active listening


People who experience pain can have trouble saying what they want to happen – and difficulty hearing what other people really have to say. OK, I agree it’s a problem for us all – but

  • pain interferes with the capacity to attend to and process information, and
  • people with pain are often engaged in systems such as compensation or the health system
  • and communicating with their families (who are often also under strain)

so it’s good to help people learn to hear what is being said, and to be able to respond honestly and ‘assertively’.

Assertiveness is, however, a loaded word. I asked the group participants today what they immediately thought of when they heard the word ‘assertiveness’ and they said being bossy, dominant, pushy – and one person said it reminded her of hairy armpits!

So here are two activities that can be helpful so people develop skills for hearing and communicating.

The one minute silence

Pair off, sitting opposite each other.

If appropriate, hold the hands of the person and look into his/her eyes (this is best carried out with people in an intimate relationship – otherwise, simply looking into each others eyes is fine).

For one minute, one of the dyad can talk about anything he or she wants to. The other partner must listen without saying anything. After one minute, swap roles.

The paraphrase

As above (and following on from the above activity). The first person in the dyad talks for one minute about an issue that has been bothering them, while the second listens. After one minute, the person listening says ‘So you mean…’ and paraphrases the key issue. The first person can say ‘that’s it!’, ‘no, you haven’t got it’, or ‘nearly’, but gives no further information. The listener must continue with paraphrasing until the first person says ‘that’s it!’.

Then the pair swap roles.

Debriefing

  1. What was it like to be listened to? (first interaction)
  2. What was it like to really listen?
  3. What was it like when the person was trying to interpret/paraphrase what you said?
  4. What was it like to paraphrase what the person was trying to say?

I often then follow with the ‘DESC’ process to help with two things – (1) identifying what the ‘real’ issue is in a conflict (describing) and being clear about the emotional impact of that behaviour (expressing); and (2) then stating what exactly the person would like to have happen.

For those of you who haven’t encountered this process it’s as follows:

D= Describe the situation, being specific about one situation or event. e.g. ‘when I asked you about getting a dog, you walked out of the room’

E= Express your emotional response, keeping to ‘I’ messages. e.g. ‘I felt ignored and ‘cut off’.

S= State what you would like the other person to do, being specific about their action (but not about the outcome you want). e.g. ‘Could we meet to talk for 20 minutes this evening about the dog?’ (eg not presuming that the person will agree with your request to get a dog!)

C= Consequences – stating what consequences will be either for you or the other person. e.g. ‘And that way I can feel that we’ve been able to clear the air’ or ‘And that way I won’t keep on asking to talk about it again’.

This article by the London Pain Consultants outlines the rationale for effective communication, while this article discusses very briefly the place of assertiveness in developing confidence for self management.

For me, self management implies that the people we work with will be actively engaged in stating what they want to have happen with regard to their lives and health, and as a result they will be changing their behaviour, and doing things differently. This necessitates communicating these changes to other people, and doing this openly and honestly.

I find I carry out quite a lot of cognitive restructuring and challenging during sessions on communication skills – because it does seem that people are unwilling to ask others to do things differently, or to put up with them doing things differently, if they have not entirely convinced themselves of the benefits.

As a result, sessions on communication can often be quite intense CBT sessions – talking alone doesn’t do the trick, it must be accompanied by role play or practice!

I’m keen to hear what you think about communication, and whether (and how) you incorporate this into your pain management.  Drop me a line and let me know! And if you’ve enjoyed this post, don’t forget you can subscribe using RSS feed, and can bookmark my blog and visit regularly.  I’m posting roughly every day/every other day, so there’s plenty to read!